Spare Me the Subjective and Objective; I seek the Assessment and Plan

It’s easy to find a well-done study to affirm how anxious and unhappy we physicians are these days. For example, the October 2012 Merritt Hawkins / Physicians Foundation survey of nearly 14,000 physicians paints a picture of individual pessimism and professional decline (see table below).

The Physicians Foundation & Merritt Hawkins, October 2012

%

Pessimistic about the future of the profession

77

Morale described as “negative” for self

58

Morale described as “negative” for colleagues

80

Profession described as “in decline”

84

Willingness to Recommend Profession to Children / Young

42

It’s harder, and perhaps more meaningful, to interpret the subjective and objective. Indeed, I suggest we stop “interviewing for pain”, and start crafting an Assessment and Plan that might improve things. Lesser physicians spend the majority of their time transcribing data into the subjective and objective portion of their progress note; greater physicians spend that time interpreting the data and crafting a path toward recovery.

The root causes of our pain seem to be (1) reductions in our autonomy (for diagnosis and treatment; for running our practice; for regulatory and contractual reasons), and (2) issues related to money (decline in payment amount per unit of care, thus driving higher number of units; patients changing doctors for coverage/cost reasons; a belief that one must work more hours for the same pay). Interestingly, these root causes have been the industry’s intentional response to the ridiculously high cost of American healthcare, as well as inadequate and unreliable clinical outcomes of that care. We physicians failed to solve the problem of runaway costs over the last 30 years, so payors sought to solve it for us by reducing our decision-making autonomy and payments per unit of care. Those “interventions” failed of course, but that’s a different article.

Our Plan must account for the root causes of the disease:

  1. If we believe (a) unwarranted variation exists in the practice of medicine and surgery, (b) some unwarranted variation leads to wasted resources and lesser patient outcomes, and (c) Evidence-Based Medicine (EBM) can reduce some of that variation, then we physicians should collaborate to create, adopt and continuously refine Best Practices, rather than lament loss of individual physician autonomy.
  2. If we believe (a) earning a salary in the top 2% of American society is sufficient compensation for our years of personal sacrifices and professional pressures, (b) being invited into the lives of people when they are most vulnerable is a unique privilege, and (c) easing pain and suffering is meaningful work, then we should emphasize a personal perspective reflective of those blessings, rather than continuously mourning the massive changes in our practices.
  3. If we believe (a) fee-for-service (FFS) compensation promotes volume over value and can misalign patient and physician interests, (b) having administrative infrastructure frees physicians and surgeons to do more of what they like to do, and (c) practicing in a fellowship of collegiality and comradery leads to professional fulfillment, then we should form self-governing multi-specialty group practices, in which each physician is accountable to one another along dimensions of quality, citizenship, and work ethic.
The Plan

% of the solution

Create, adopt and continuously refine Best Practices, led by physicians

20%

Practice a personal perspective that reflects the blessings of our profession

30%

Form large, self-governing multi-specialty group practices, organized around the principles of humble service, patient-centered care, and continuous improvement

50%

We must stop focusing on our personal and professional pain and start focusing on how to restore the fulfillment, the culture of humble, altruistic service, and the scientific method to our beleaguered profession.

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